News:RACE study: Statewide System for Coronary Reperfusion for STEMI Patients Can Improve Quality of Care

November 4, 2007 By Katherine Ogando [1]

Orlando, FL: RACE (Reperfusion of Acute MI in North Carolina Emergency Departments) investigators were successful in the implementation of a state-wide reperfusion system that aimed at increasing the number of provisions of reperfusion therapy and decreasing the delay in the administration of therapy in the state of North Carolina. The outcomes of the study were presented by Dr. Christopher Granger at the American Heart Association Scientific Sessions 2007, and published in the Journal of the American Medical Association.

The RACE study arose out of a need to improve quality of care citing the importance of treating MI patients with adequate speed as potentially life saving. Prior research has indicated that prompt reperfusion after a myocardial infarction may significantly reduce morbidity and mortality. The goal of the study is to overcome systematic barriers that hamper cooperation between PCI and non-PCI hospitals, and thus lower the quality of care. The authors hypothesized that an implementation of a coordinated system of reperfusion would decrease delays in the delivery of reperfusion therapy and increase the number of patients receiving it.

The study was centered across 5 regions in North Carolina involving 10 PCI hospitals and 55 non-PCI hospitals (n=65). Throughout the intervention, PCI hospitals treated 1164 STEMI patients that were eligible for reperfusion. The median age of the patients treated at PCI hospitals was 61 years, with 31% being women, and 4% Killip class III or IV. Non-PCI hospitals treated 925 STEMI patients. The median age was 62 years, 32% were women, and 4% were Killip class III or IV. The study took place over the course of a year and the main outcomes were measured 3 months before and 3 months after the intervention.

Participating PCI hospitals consented to establish a system by which prior authorization to activate the catheterization laboratory was unnecessary and only a single telephone call from emergency physicians or paramedics was required. The hospitals also agreed to disregard bed availability to accept STEMI patients. Each participating PCI hospital had to establish a leadership team and be able to provide services without regard to affiliations. The interventions established in the hospitals focused on early diagnosis and the coordination of the initial emergency medical response with the emergency medical systems, emergency department, catheterization laboratory, and transfer.

The main outcome measures included the reperfusion times and rates from July to September 2005, or 3 months before the intervention, and from January to March 2007 (3 months after the intervention). Reperfusion times in PCI hospitals were reduced from 85 minutes pre-intervention to 74 minutes post intervention (p<0.001) and from 165 to 128 minutes in patients transferred from a non-PCI hospital to a PCI hospital. The door-to-needle (fibrinolytic therapy) time in non-PCI hospitals was reduced from 35 to 29 minutes (p=0.002). Door-in door-out time for transfer patients decreased from 120 minutes to 71 minutes (p<0.001). Non reperfusion rates in non-PCI hospitals remained constant before and after the intervention at 15%, whereas it demonstrated a decrease in PCI hospitals from 23% to 11%. There was no difference in clinic outcomes, however, pre- and post-intervention.

The results of the RACE study correlate a coordinated system and an improvement in the quality of care provided to STEMI patients, illustrated by the decrease in treatment delay and increase in number of patients treated. The improvement in quality of care fails to translate into improved clinical outcomes for STEMI patients, however. Though timing and speed are critical factors in the outcome of reperfusion therapy, it could be speculated that there are other variables that may affect clinical outcomes. Further research is necessary to determine what variables are more effective in improving care.

This study has several limitations. Because it is not randomized, has a limited sample size, and has various confounders, any interpretations made based on the results should be analyzed with caution. Other limitations identified by the authors were the lack of an entity with which to compare the progress in care against, as well as the possibility that deaths that occurred during transfer were not reported, and the exclusion by non-PCI hospitals of certain patient information.

This study was funded by Blue Cross and Blue Shield of North Carolina.

References

1. JG Jollis, ML Roettig, AO Aluko, KJ Anstrom, RJ Applegate, JD Babb, PB Berger, DJ Bohle, SM Fletcher, J Lee Garvey, WR Hathaway, JW Hoekstra, RV Kelly, WT Maddox Jr, JR Shiber, F Scott Valeri, BA Watling, B Hadley Wilson, CB Granger. Implementation of a statewide system for coronary reperfuion for ST-segment elevation myocardial infarction. JAMA 2007; 298(20).